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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />r - SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE UFRMIJ C 09 953-7 7 OR INSPECTIONS EXPIRES 1 YEAR FROM SS ED <br />JOB ADDRESS CITY/ZIP.d <br />CROSS STREET i/ �[/ _ APN — 1 � 0 _. PARCEL SIZE <br />OWNER NAME r`IPHONE may, <br />OWNER ADDRESS IRiCTY/STATE/ZIP jig 1 <br />CONTRACTOR t� PHONE�\�GL©�-C� <br />CONTRACTOR ADDRESS1q3/00"i-•J CITY/STATE/ZIP <br />LICENSE ❑ iC-42 [1 -C -36C-36 OTHER tr,A.IVAL4Jl Qt <br />NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: too , ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION gL REPAIR/ADDITION _ ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT _ OUT -OF -SERVICE SEPTIC SYSTEM _ DESTRUCTION <br />INSTALL ATIONWILL SERVE: ® RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE To NEAREST: WELLft FOUNDATION ft PROPERTY LINE 5ft <br />❑ LIFTSTATION SIZE -TYPE OF PUMP ❑ PKGTXPLANT ❑ SAND OIL SEPARATOR(ENCLOSEDSYSTEM) <br />❑ LEACH LINES <br />G LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />R <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />It DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />It PROPERTY LINE ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />SIGNED <br />Application Accepted By <br />Final Inspection By I <br />Character of Soil to Dgptl <br />COMMENTS? <br />T -t4.l- <br />i <br />PEw SC Ret <br />Code INFO <br />0 <br />L <br />Date <br />Date <br />— <br />3 <br />3 Ft: <br />ad Check#/ Amount Date <br />Cash Remitted <br />Area ((z <br />❑ SPE <br />Soil Character: <br />Service Request # <br />H <br />Y <br />O <br />3 <br />q,�2y o <br />Ro VAN co ®?I <br />� pMFNr�N)Y <br />'gRT�FNT <br />Employee ID# \_� I v• v – <br />RMIT - Approved by <br />Invoice # Permit ID# <br />`tV4,1114'Ir <br />�e,�,`1� <br />42-01��'��� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4114/18 S <br />